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The Future of Electronic Clinical Documentation

December 1, 2013
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Many physicians complain that a data entry system with templates loses the fluid narrative structure of written notes

At the recent AMIA symposium in Washington, D.C, one interesting panel discussed the future of clinical documentation. Panelists said providers identify many benefits from the shift to electronic clinical notes, including being able to access the notes from anywhere, but many problems persist. Physicians often identify the loss of the patient story from the encounter and the increase in time they spend in front of the computer instead of with patients.

Thomas Payne, M.D., an associate professor in the Department of Medicine at the University of Washington and medical director of Information Technology Services for UW Medicine, began his discussion by showing a photo of his offices -- and pointed out that all of the clinicians were staring at computer screens.

He said that a recent study found medical interns spend 40 percent of their time in front of computer screens and more time reviewing patient charts than directly engaging patients. “I don’t know what the correct percent is, but it seems to me that 40 percent is a little high,” he said.

 “It is an important issue for us to quantify and improve upon,” Payne said. “What we learn the most from is human interaction.” Because UW has been using electronic notes for only seven years, he said, it is not surprising their use is far from perfected yet.

S. Trent Rosenbloom, M.D., the director of patient engagement and an associate professor of biomedical informatics at Vanderbilt University, noted that the array of tools available to create notes is an ever-changing landscape, including templates, dictation and speech recognition. Each technology has advantages and disadvantages.

Computer-based documentation that is heavy on typing is not efficient for clinicians. Software with templates to help physicians write notes can lead to greater efficiency by importing information it knows about the patient, Rosenbloom said, but of course it can import incorrect information as well. Many physicians surveyed complain that a structured data entry system loses the fluid narrative structure of the written notes.

Payne said one solution is to tell the patient’s story but in less time by using automation including natural language processing to extract meaning from the patient interaction.

Peter Embi, M.D., Vice-Chair of the Department of Biomedical Informatics and chief research information officer of the Ohio State University Medical Center, described a recent study he led at five Department of Veterans Affairs facilities. What their focus groups found was that the current clinical documentation systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated “paper-chart” paradigm.

“There is a feeling that the electronic notes don’t impart a story, a flow,” Embi said. “They make it tough to piece together the patient’s story and are not as easy to search as Google.” That also impacts secondary uses, he explained, because the data is often difficult to access for research. “We want to leverage documentation for learning, but we haven’t designed it with that in mind.  We have a valuable, rich source of information,” Embi added, “but a lot of what went into the development of these systems is about treating one patient at a time. So we struggle in leveraging data for research and quality improvement.”

Despite all the negative comments his study heard about the time and effort burdens of electronic documentation, nobody wanted to go back to paper. “They all thought that was worse,” Embi said.